The Zero Trimester. Miranda R. Waggoner
Читать онлайн книгу.
prenatal care in the early twentieth century,39 but this concept did not take root as a universal expectation of pregnant women until the 1980s.40 The ’80s became known within the maternal and child health field as one of a “prenatal care revolution” because of the great increase in numbers of women seeking and accessing care.41 Maternal and child health experts were hopeful that this surge in prenatal care utilization would reveal its “magic bullet” status, translating into vast improvements in population health. Quite surprisingly and contrary to the expectations of many, however, birth outcomes did not improve the more prenatal care American women sought and received. At the end of the twentieth century, infant health and survival in the United States ranked among the worst in the industrialized world and improvement in rates of adverse birth outcomes had stagnated.42
Such it was that a paradox had emerged—more and more women were accessing prenatal care services without parallel improvements in birth outcomes. When prenatal care seemed not to be doing enough, prenatal education was then pushed as the next big answer.43 Sociologist Elizabeth Mitchell Armstrong writes that prenatal education, such as childbirth classes offered by hospitals, was “proposed as a solution to one of the most troubling social facts of contemporary America: despite the billions of dollars lavished on health care, despite ever-higher concentrations of medical technology, babies continue to die in this country at a much higher rate than elsewhere in the industrialized world.”44 Because many countries use infant and maternal mortality and morbidity rates as proxies for national health,45 the United States did not distinguish itself as healthy or progressive in the 1980s. Experts began to question the evidence bolstering prenatal care. Maternal and child health scholar Lorraine V. Klerman wrote in 1990 that it was perhaps time to “question past orthodoxies” and “loosen the link between prenatal care and infant mortality” because “public health experts know that the reduction of infant mortality requires much more than prenatal care.”46 In the interviews I conducted for this book, experts told me time and again that prenatal care basically does very little, if anything, to address the nation’s most pressing maternal and child health problems.
Although prenatal care might be very effective at diagnosing and treating problems that surface during a pregnancy, it does not prevent many of those issues from arising in the first place. It is especially ineffective at preventing the major causes of poor infant health outcomes: low birthweight and preterm birth.47 Moreover, health professionals are quick to note that almost half of U.S. pregnancies are unplanned, meaning that women often enter pregnancy without health care or healthy behaviors on their mind, and unintended pregnancies are often linked to a greater risk of an adverse birth outcome.48 Many experts argue that U.S. women are just not healthy enough—and do not plan ahead well enough—and therefore are putting the health of the next generation at risk. In this vein, and as Chapter 4 discusses in more detail, health experts began to question policies that only provide comprehensive health care to women when they are pregnant, rather than before and beyond motherhood. Thus, around the turn of this century, many maternal and child health professionals considered prenatal care—the perceived panacea for improving the population’s birth outcomes—nothing more than a mere salve.49 As one historian has written, “prenatal care is no magic bullet and never will be.”50
What was considered the best way forward? How do medical and public health experts tackle population health problems when the best idea to date has not worked? Near the turn of the twenty-first century, maternal and child health experts began contending that the answer to improving birth outcomes and to reducing infant mortality and maternal mortality was both prenatal care and pre-conception care,51 or medical and health attention before pregnancy ever begins, in addition to care during pregnancy itself52—that is, to construct a zero trimester. If prenatal care seemed to be the answer for the twentieth century, then pre-pregnancy care would be the answer for the twenty-first.
In 2004, the Centers for Disease Control and Prevention launched the Preconception Health and Health Care Initiative, signaling a formal swing in policy focus toward improving women’s health status through a focus on both individual women’s self-care and improvement in health-care services for women of reproductive age prior to pregnancy. But how far prior? The answer was to move the temporality of pregnancy health risk and maternal responsibility to actions taken in the months—or sometimes even years—before pregnancy, thus situating essentially any body of reproductive age as posing risk to healthy reproduction.
This book examines this redefinition of reproductive risk; it is about a knowledge shift in the field of maternal and child health—about a search for a panacea in pregnancy care. It looks at the collective response to pressing population health and social problems when the clinical “fix” has failed, and it is about how a somewhat ambiguous idea of “pre-pregnancy care” came to “make sense” in medical and public-health discourse today.
DOES THE ZERO TRIMESTER MATTER?
EVIDENCE AND AMBIGUITY
Of course, prenatal care did not become obsolete and instead has been bolstered time and again by social policy initiatives.53 Prenatal care remains an “article of faith” in our culture,54 and individuals, couples, doctors, health policy, and insurance companies continue to highly value it. To repeat, prenatal care does have individual-level benefits such as addressing and diagnosing problems that arise during a pregnancy, and the central argument of this book in no way posits that women’s access to prenatal care services should be curtailed. What is germane here is that prenatal care does little in the way of primary prevention—a point that the medical experts I interviewed readily and repeatedly made. This means that prenatal care is reflective of our medical culture to treat rather than prevent.55 It inscribes maternal responsibility as a “good” expectant mother seeking prenatal care throughout her pregnancy. Pre-pregnancy care, then, might seem an obvious next step for individuals and organizations immersed in the idea that seeking prenatal care marks responsible pregnancy behavior: if it is good, then the earlier the better. The added component of pre-pregnancy care was meant to complement, not supplant, the “old” prenatal model, and in so doing expand the sphere of medical and maternal responsibility for establishing healthy pregnancies.
Although the pre-pregnancy care model in some ways might be an empowering and smart way for women and physicians to approach family planning and reduce risk—and, indeed, the focus on pre-pregnancy care offers an important corrective to longstanding policies that have ignored the critical intersections between maternal health and reproductive health and that have in some ways impeded reproductive justice (a point explored at length in Chapter 4)—it in other ways might function as yet another attempt to control women and their behaviors, by placing their non-pregnant lives within new crosshairs of public scrutiny. To be sure, much of the criticism surrounding the pre-pregnancy care model has stemmed from the fact that pregnant women have long been construed as “public property” in America,56 where, at an interactional level, strangers feel empowered to touch pregnant women’s bellies and, at a structural level, the criminal justice system targets pregnant women for their behaviors. Surveillance of, and anxiety around, women’s pregnant bodies remains typical. Imagine a visibly pregnant woman drinking at a bar in the United States; the social sanctioning that follows is perhaps inevitable. Then, imagine a non-pregnant woman drinking at a bar. Does anyone look at her and worry about her future fetus? Not likely. For a very long time, medicine, public health, and even the lay public have focused intently on policing a woman’s behaviors when she is clearly pregnant. Few people—and few physicians—would think of telling a non-pregnant woman who drinks alcohol that she is possibly harming her chances of having a healthy baby someday. Yet this message is part of the CDC’s 2016 public-health statements urging women of reproductive age to avoid alcohol. Even if the message might be well-intentioned in some respects, these types of directives run the risk of unintended consequences—namely of creating an atmosphere that escalates not only individual guilt among women but also social policing and public retribution against women who deviate from customary norms.
But is the hypothetical non-pregnant woman drinking at a bar actually endangering her future fetus? Do everyday choices and behaviors matter for future reproductive outcomes? It might make